Mandatory Spending
Function 570 - Medicare
Change the Cost-Sharing Rules for Medicare and Restrict Medigap Insurance
CBO periodically issues a compendium of policy options (called Options for Reducing the Deficit) covering a broad range of issues, as well as separate reports that include options for changing federal tax and spending policies in particular areas. This option appears in one of those publications. The options are derived from many sources and reflect a range of possibilities. For each option, CBO presents an estimate of its effects on the budget but makes no recommendations. Inclusion or exclusion of any particular option does not imply an endorsement or rejection by CBO.
Billions of dollars | 2025 | 2026 | 2027 | 2028 | 2029 | 2030 | 2031 | 2032 | 2033 | 2034 | 2025– | 2025– | |
Change in outlays | |||||||||||||
Establish uniform cost sharing and an out-of-pocket cap for Medicare | 0 | 0 | 0 | -2 | -3 | -3 | -3 | -3 | -3 | -3 | -5 | -20 | |
Restrict medigap policies | 0 | 0 | 0 | -11 | -15 | -16 | -17 | -18 | -19 | -20 | -26 | -116 | |
Implement both alternativesa | 0 | 0 | 0 | -13 | -18 | -18 | -19 | -20 | -20 | -21 | -31 | -129 | |
This option would take effect in January 2028.
a. Although the total savings of this alternative would approximate the sum of the savings from the first two alternatives, that relationship might not apply if different dollar amounts for the deductible and out-of-pocket cap were used.
In the traditional fee-for-service (FFS) portion of the Medicare program, cost sharing—the payments for which enrollees are responsible when they receive health care—varies significantly depending on the type of service provided. Cost sharing in FFS Medicare can take the following forms: deductibles, coinsurance, or copayments. Deductibles are the amount of spending an enrollee incurs before coverage begins, and coinsurance (a specified percentage) and copayments (a specified dollar amount) represent the portion of spending an enrollee pays at the time of service.
Under Medicare Part A, which primarily covers services provided by hospitals and other facilities, enrollees are liable for an initial copayment (sometimes called the Part A deductible) of $1,632 (in 2024) for each "spell of illness" that requires hospitalization and substantial daily copayments for extended stays. Under Medicare Part B, which mainly covers outpatient services, enrollees pay an annual deductible of $240 (in 2024) and generally pay coinsurance of 20 percent of allowable costs in excess of that deductible. There is no annual cap on enrollees' Medicare cost-sharing payments. Therefore, most people enrolled in FFS Medicare have some form of supplemental coverage that reduces or eliminates their cost-sharing obligations and protects them from high out-of-pocket costs. The most common way people obtain supplemental coverage is by purchasing specialized insurance policies, known as medigap plans, directly from insurers. Other Medicare enrollees retain coverage from a former employer as retirees. Medicaid also covers Medicare's cost sharing for most people who enroll in both Medicare and Medicaid.
This option consists of three alternatives that would all take effect in 2028. The first alternative would replace Medicare's current cost-sharing requirement with a single annual deductible of $850 for all Part A and Part B services, a uniform coinsurance rate of 20 percent for all spending above that deductible, and an annual out-of-pocket cap of $8,500. The second alternative would leave Medicare's cost-sharing rules unchanged but would restrict existing and new medigap policies. Specifically, it would bar those policies from paying any of the first $850 of an enrollee's cost-sharing obligations for Part A and Part B services and would limit coverage to 50 percent of the next $7,650 of those cost-sharing obligations. Medigap policies would cover all further cost-sharing obligations, so policyholders would not pay more than $4,675 in cost sharing. The third alternative would combine the changes from the first and second alternatives. After 2028, dollar amounts in all three alternatives—the combined deductible and cap (the first and third alternatives) and the medigap thresholds (the second and third alternatives)—would be indexed to the rate of growth of average FFS Medicare spending per enrollee.